The Patient Protection and Affordable Care Act called for Medicare to launch ACOs. The program expanded rapidly to total roughly 370 organizations as of January, with more to come.
Medicaid, in some states, and commercial health plans also have entered accountable care contracts with doctors and hospitals. New incentives under accountable care could erode the inducement for providers to do multiple tests and procedures when insurance companies pay by the exam, clinic visits or laboratory test.
Incentives for the earliest ACOs, however, are widely considered too small and weak. Rather, physicians who will use their clout to sway others to change practice patterns are considered important to ACOs' success, researchers wrote in Health Affairs.
Doctors who use their influence to promote quality and efficiency efforts are important, the paper said, and adding physicians to governing boards is one avenue to build the necessary trust to win over physician leadership.
Early ACOs have done just that. Doctors accounted for more than half the governing board among three quarters of the 173 public and private ACOs surveyed by Carrie Cola, Valeria Lewis and Elliott Fisher of Dartmouth University and Stephen Shortell of the University of California at Berkeley. Doctors owned 40% of the ACOs in operation as of August 2012.
ACOs described as “physician-led” composed 51% of survey respondents and another 33% were led by doctors and hospitals.
Separately, physician-led Medicare ACOs dominated the four case studies (three out of four) profiled in a second Health Affairs analysis http://content.healthaffairs.org/content/33/6/972.abstract of surgeons' roles in accountable care.
The ACOs' top strategic priorities—fewer readmissions and emergency room visits, more coordination for the chronically ill—did not include surgical care. And surgeons were absent from the executive committee of two of the four ACOs. The researchers also surveyed early Medicare ACOs and 14 of 28 respondents said no surgeons sat on their executive committee.
One reason for ACOs lack of interest in surgeons? “Notably, none of CMS' 33 ACO quality measures directly addresses surgery or surgical care,” wrote authors James Dupree, formerly of the American College of Surgeons; Kavita Patel of the Brookings Institution; Mallory West, formerly of Brookings; and Sara Singer, Rui Wang, Michael Zinner and Joel Weissman of Harvard University. Quality measures must be met under Medicare's accountable care program before ACOs can earn financial bonuses.
Surgeons also lack a strong incentive to join ACOs, the researchers wrote. The relatively minor ACO incentives are believed to be too inconsequential to change surgeons' behavior on quality or cost targets, case study ACO officials said. (Referral patterns may give ACOs more clout in negotiations, which officials said they plan to explore.)
Surgery failed to rank among the high-priority targets for ACOs, the paper said, and 88% of surveyed ACOs did not know what role surgery played in total spending.
That may prove to be a costly oversight. “Nationally, surgery represents approximately 50% of hospital expenditures and accounts for an estimated 30% of total healthcare costs,” the authors wrote. “Thus, even if ACOs are able to achieve their goals in chronic disease management, overlooking the role and cost of surgical care may negate those savings.”
